Creation of the role

The role of Chief Coroner was created by the Coroners and Justice Act 2009, in the aftermath of the Harold Shipman murders. Dame Janet Smith’s review of the inadequacies of the death registration regime, which facilitated the background to Shipman’s crimes, identified in its third report that “there must be a radical reform and a complete break with the past, as to organisation, philosophy, sense of purpose and mode of operation” of the coronial regime. The Act was intended to address the issues identified in the “Shipman Inquiry” and the extensive “Fundamental Review of Death Certification and Investigation”.

It is not that the reforms were going to cost a significant amount of funding. The previous government estimated that most appeals would be dealt with on paper and that in any event, the cost to the legal aid budget would be in the region of £100,000 per year (see p 147, para 5.25 of the consultation paper).

A lateral organisation

So it was that the introduction of the role of Chief Coroner was welcomed by bodies ranging from the Bar Council to the pressure group “Inquest”. The advantages of the post seemed clear cut. One of the handicaps of the present system is inconsistency, both in procedure and decision-making. The Chief Coroner was expected to provide a lateral organisation of the coronial system, bringing with it both consistency and accountability. The new appeal process to the Chief Coroner, albeit, substantially and inexpensively on the papers, was seen to go some way to alleviating pressure upon bereaved families to seek judicial review of coroner’s decisions and the consequent exposure to costs if the Administrative Court finds against them.

Here of course was the essence of the reform objectives – allowing bereaved families to properly and effectively participate in death investigations, which is not only forensically desirable but also a part of the process of grieving.

Indeed the “Charter for Bereaved People” utterly supported by the previous government stressed as its central principle the involvement of the bereaved in the coronial process and the Chief Coroner’s importance in the appeal regime.

The public are sadly becoming increasingly aware of the Coroner’s Court. High profile inquests, such as the on-going 7/7 inquest and the seemingly endless list of inquiries into military deaths in the theatre of war continue to raise the coronial process in the public mind. Last year, coroners in England and Wales were notified of 230,000 deaths. This represents nearly 45 per cent of all deaths that occurred in England and Wales and means that many bereaved families have contact with coroners and their staff, as do those working in the health service, the police, local authorities and other public services.

All the more reason for the coronial process to be fit for purpose and available, without adverse cost risks, to all, who sadly, have to use it. The appeal process before the Chief Coroner provided this sort of access.

Leadership and support

In his foreword to the 2009 Bill, Lord Falconer described the perceived role of the Chief Coroner to provide leadership and support to the system, to develop natural standards and guidance, to advise and support other coroners and the government and to be, through the Lord Chancellor, accountable to Parliament.

Reason for abolition?

All this seems to be on the verge of being swept away. It will be interesting in the weeks to come to understand what the Coalition’s explanation is for abolishing the role of Chief Coroner before it began. But it will be even more enlightening to hear their rationale for rejecting the lengthy, erudite and critical conclusions, both by the “Shipman Inquiry” and other respected bodies. It is not inappropriate to ask whether the lessons of Shipman have really been learned by this government. 

John Cooper QC, 25 Bedford Row, is the Consultant Editor of Criminal Law & Justice Weekly. His book “Inquests” will be published by Hart Publishing in December. This article first appeared in NLJ (22 October 2010)